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Ear surgery: An anesthetic technique without nitrous oxide (to avoid hyperpressure in the middle ear) and muscle relaxants (to allow stimulation of the facial nerve) has to be used. This provides a first-hand experience of the pharmacodynamics and side effects of inhalational anesthetic agents. Total intravenous anesthesia (TIVA) can be used as an alternative. Laser surgery: Prevention and management of airway fires, special endotracheal tubes, and jet ventilation are distinctive aspects of anesthesia for laser surgery. Oral surgery: While not part of otolaryngology proper, oral surgery cases usually require nasotracheal intubation, and often controlled hypotension to limit bleeding for mandibular / maxillary osteotomies. Another challenge is that of the uncooperative patient scheduled for dental restoration. Airway: The airway management workshop is a one-week rotation for residents, providing hands-on training, with the help of an airway mannequin, on the management of the difficult airway and the various tools at our disposal. The clinical rotation offers a unique exposure to the assessment and management of the abnormal or difficult airway, whether it is because of patient anatomy, of a tumor, of prior radiation, of obstructive sleep apnea or of enlarged tonsils. Residents can practice and perfect techniques such as fiberoptic intubation, retrograde intubation, cricothyroidotomy and jet ventilation, as well as intubation using a lighted stylet, the intubating LMA or the ILA, the Bullard scope, and the Glidescope. The management of patients with recognized and unrecognized difficult intubation is discussed in detail, keeping in mind that this field is evolving fast at the present time. Emergence and extubation of the patient with a difficult airway can be challenging as well, as is the management of emergencies such as bleeding following tonsillectomy. Arthur Atchabahian, MD |
The rotation in otolaryngology / head and neck surgery presents some unique aspects. In no other area is the airway shared to such an extent with the surgeon. Communication with the surgical team is therefore of the utmost importance. Some techniques, such as anesthesia without the supplementation of nitrous oxide or muscle relaxant, are also specific to this area. Cases range from minor outpatient sinus surgery to major tumor resection with extensive neck dissection. Case turnover is often fast, necessitating precise tailoring of the anesthesia to patient needs. Prevention of post-operative nausea and vomiting is also paramount.